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Discussion

Nursing errors? Charting inconsistencies?

Hi there. This is my first quarter as a nursing student at clinical, so forgive me if I don't really know what I am talking about! However, I do enjoy staying up to date on medical topics- and my patient at clinical seems like he is not being taken care of adequately, and I would like your opinion. He has anoxic brain damage, diabetes, dysphagia, hypertension, chronic kidney disease (Just entered into stage 3 with a gfr of 58 and creatine around 1.4, no edema noted, but it has been noted in chart before). He is taking a ccb, klonapin, medication for constipation, insulin, and maybe ranitidine, and Tylenol prn. I think that is it. I know for sure (checked with others) he is taking no medications for hyperlipidemia, although on his chart he is noted to have hyperlipidemia. I reviewed all of the labs in his chart with another person, and there is no lipid panels whatsoever, although I don't know if they add everything to his chart (like things older than 1 year).... His diabetes and hypertension appear to be well controlled with no bp measurements of over 140 in quite awhile... and gc measurements are very well controlled also. Patient has recently developed cardiomegly (LVH) in the past six months (confusing to me as his bp was controlled) and atelectasis about a week and a half ago (patient had x-ray for cough). At this time, no new nursing plans were done to treat this (no new incentive spirometry, increased temperature readings, or coughing exercises). Directly asked the nurse and she said the doctor had not ordered any new orders after the x-ray. I was of course worried about the cough, which now sounded wet... and we found crackles and a temperature of 101.5, which we notified the nurse of. She was very surprised, and we checked his chart, and 15 minutes before we went in to check, she had posted in his chart something like, "patient doing fine. Lungs clear to asustation" The vital signs (temperature) had not been checked for at least the past five days. Patient was immediately started on an antibiotic for potential pneumonia and o2, as his sp02 was less than 90, but an x ray wasn't ordered until 2 weeks from now. I am concerned this patient is not being adequately taken care of. We are going to the supervisor, but what are your thoughts about this patient? Thanks for all your help!

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    Sorry forgot to mention, patient is on an ace, lisinopril and timolol for glucoma.

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    It could be that he is not on a statin because of a potential drug interaction. For example, if his CCB is verapamil, both simvastatin and lovastatin are to be avoided. The risks vs. benefits of treating the hyperlipidemia would have to be weighed, and most likely the benefits of taking a CCB are greater than those of a statin in the overall scheme of things.

    It sounds like the physician is presuming pneumonia vs. heart failure due to the fever. Starting antibiotics and adding supplemental O2 have diagnostic value. If the patient improves, then it was pneumonia. If not, then further evaluation for heart failure would be indicated.

    Also, what are the patient's own wishes for his care? What are the goals of treatment for him? Does he want conservative treatment with an emphasis on comfort, or does he want aggressive intervention? Is further decline an expected course for him, or is it expected that he will improve or maintain the same level of health for an extended period of time? Could there be something you are not privy to related to this patient's expected course/prognosis/wishes?

    What kind of setting is this? There are huge differences in how things work in acute care vs. long term care. This sounds like maybe a SNF or LTC, and keep in mind that while you have only one patient in clinical, the nurse likely has 30 or more. It's a fact of life that nurses with that kind of patient load are simply unable to provide a level of monitoring consistent with having only one patient. Also, they are working with doctors that are out of house and whose availability is more limited than in an acute care facility. Labs and diagnostics are out of house and have to be scheduled. If a patient is so sick that they can't wait, then they go to the ED.

    Maybe your meeting with the supervisor will help your understanding and will result in a positive outcome. Hopefully it won't result in someone being thrown under the bus because company policy and working conditions make it impossible for nurses to watch every single patient like a hawk.

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    For what its worth, I wonder about drug interactions between statins and ranitidine and statins and verapimil (if that's the ccb he's on). I wonder if his physician felt those risks were too big to take. Also wondered if you have any labs on him at all to show when and at what levels he had hyperlipidemia.

    Also wondered if has taken statins before and perhaps been unable to tolerate them/had a reaction to them. Did he perhaps develop elevated lfts during a time of previous statin admin? Does he have any liver dysfuction, elevated lfts?

    I guess those are some things I'd want to know (noting that I am just a beginner at this sort of thing).

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